Family of woman found dead on floor of Montreal ER still waiting for answers 1 year later

A year after 86-year-old Candida Macarine was found dead on the floor beside her bed in the emergency room at Lakeshore General Hospital in Montreal's West Island, her family is still waiting for answers about her death.

And, they say, changes promised by the hospital still haven't materialized.

"It keeps coming back in my thoughts. It's always coming back. What happened to my mom? What really happened that night?" Candida Macarine's daughter, Gilda Macarine, told CBC in an interview with the family Thursday.

Candida Macarine's son, Emmanuel, told CBC the lack of information is painful and frustrating.

"Sunday will be the first-year anniversary of her death. I was really hoping that I could visit her grave with some answers and closure," he said.

"I want to say something that could make me feel better, and show my mom that she can finally rest in peace," Emmanuel Macarine said, choking up.

Gilda Macarine works as nurse herself in a long-term care home. She said that makes it even harder to accept what happened to her mother.

"Everday, I see these elderly people I'm taking care of and my heart's still so heavy, and sometimes my tears just come out," she said.

Candida Macarine was the matriarch of a large, extended Filipino family in Montreal, and both Gilda and Emmanuel say her death is still hard for the family to talk about.

They've been in the dark about what happened from the start, and they've encountered bureaucratic roadblocks on every step of their effort to find out the truth.

Staff warned managers before death

She was found dead beside her bed on the floor of one of three negative-pressure rooms in the ER used for suspected COVID-19 patients.

Nurses had warned managers several times in the weeks prior to Macarine's death about problems being able to see directly into those rooms, making it difficult to monitor patients there.

At the time, the hospital did not tell Macarine's next of kin that she was found on the floor. The family learned of that only after reading a CBC story about the death two weeks later — the night before her funeral.

The local health agency that oversees Lakeshore, the CIUSSS de l'Ouest-de-l'Île-de-Montréal, eventually apologized for what it called "incomplete communications" with the family.

It was only after this that the CIUSSS asked the Quebec coroner's office to investigate the death.

Family's ongoing struggle to get answers

The family's headaches didn't end there.

The coroner who was appointed to the case was eventually forced to step aside, after the family discovered that she had previously worked as head of the legal affairs for the CIUSSS and could be in conflict of interest.

A new coroner was appointed. A spokesperson for the Quebec coroner's office told CBC this week the coroner's investigation is ongoing.

The family said they haven't received any updates about the investigation from the coroner's office or an idea of when it might be finished.

"I check my email every day and nothing," Emmanuel Macarine said.

The family also requested that the hospital turn over their mother's complete medical file, but the hospital ultimately refused.

The Macarines said the hospital had initially promised to keep them updated about the case and about any changes made in the ER.

"They said the family would be informed of any progress. And finally, no, we haven't heard anything them since last June," Emmanuel Macarine said.

Promised renovations haven't happened

Last May, the CIUSSS told CBC that it would make changes to improve safety in the ER.

At that time, an orderly was posted near the three isolation rooms 24 hours a day to keep an eye on patients there. That protocol is still in place.

The hospital also promised renovations to the workspace in the ER to make it safer.

At the time the hospital said the renovations would begin "in the coming days."

Today, a year after Macarine's death, the renovation work still hasn't begun.

"Due to infection prevention and control guidelines, we are unable to complete renovations at the rate we would like," Hélène Bergeron-Gamache, a spokesperson for the CIUSSS, told CBC in an email.

Emmanuel Macarine said that's unacceptable.

"Well, how long are you going to wait? Are you going to wait until someone else dies?" he said. 

Bergeron-Gamache said some measures have been taken to improve patient safety.

"We have increased continuous training for care staff, ordered 'smart cushions' that will alert care staff when a patient is getting up, and night lights for the three negative pressure rooms so that we can have eye contact," Bergeron-Gamache said.

The hospital's risk-management team also completed an internal investigation after Macarine's death.

"Recommendations came out of it, including the optimization of the rounds process with regard to the isolation rooms, new since the start of the pandemic," Bergeron-Gamache said.

She was unable to provide a copy of the risk management team's findings. Such reports are confidential under the Health and Social Services Act.

Source tells CBC little has changed

A source who works at the hospital with knowledge of the situation told CBC they hadn't seen any evidence of these changes.

The source noted the smart cushions and night lights may have been ordered, but are not yet in place.

And the source said they hadn't seen any evidence of increased training or "optimization of the rounds process".

The source said the only change they have observed is the posting of the orderly outside the three rooms in question.

Last March, a spokesperson for provincial Health Minister Christian Dubé told CBC the ministry would closely monitor the situation and apply the recommendations of the internal investigation.

This week the same spokesperson referred questions to the ministry.

No one from the ministry responded to CBC's request.